1. Sato, Hui-wen (Alina) MPH, MSN, RN, CCRN


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It feels as though every week I hear of yet another one to two colleagues who are leaving our pediatric ICU (PICU). They're at all kinds of experience levels. Some have only been on our unit for a couple of years, and some have been with us for anywhere from eight to 15 years.


Reasons colleagues leave. Some leave because they realize as young nurses that they don't want to be around so much pediatric death and dying in the long term, so they move on to other positions where they can care for healthier populations. Some leave because they've already been around so much pediatric death and dying for so long by now that it's time to practice in different spaces for their own mental and emotional well-being. Some leave for the significantly higher pay offered for travel nurse positions, and some leave to be closer to family in other states. A smaller percentage leave quietly without ever really disclosing the reasons why.


Every departure hurts on a numbers level. At a time when nurse staffing seems to be at critically low levels everywhere, raising our workload and stress levels to all-time highs, every departure hurts on a sheer numbers level, no matter how understanding and supportive I may feel of the individual and their reasons for leaving. As someone who occasionally takes on the relief charge nurse role, I tend to look ahead at our schedule to see what the staffing on my charge nurse shift will be like, as well as the staffing on the night shift after me. It gives me an idea of how busy and stressed my colleagues will be that day, how anxious I will feel about unexpected emergencies that I may not have adequate staffing for at nighttime, and how much I will need to mind-bendingly negotiate with our hospital's house supervisor, our physicians, and the charge nurses on other units to figure out how to make these fast-falling Tetris blocks fit into spaces I don't feel I have.


The deeper loss to the team. But there's more to it than just the numbers game. Even as I write this, I feel my emotions swell. It's the loss to the team spirit that I feel most acutely. It's the goodbye to people who feel like family. It's the loss of the deep understanding I've felt with people whom I've been in the trenches with for years.


Our unit has always been a tight-knit one. We've all said that it's the deep camaraderie that has helped us stick it out through the darkest of seasons and has kept so many of us here when the work has felt so excruciatingly painful.


Stacy had already been on our unit for about four years (names have been changed) before I started there as a brand-new nurse. I always admired her for her deep steadfastness. She was never overtly emotional, but you could tell she cared deeply about each patient. She never spoke harshly or judgmentally about anyone, was fastidious in her care and her charting, and handled emergent situations with a clarity of mind that always calmed and reassured me when I felt panicked. Life took her on some unexpected personal detours, leading her to the difficult decision to move out of state to be closer to family.


When I heard she was leaving, I supported her wholeheartedly on a personal level. Of course, I felt the loss in the numbers game. But what I felt more deeply was the loss of her steadfast hand, the loss of that comfort she brought me in moments of my own panic. I felt those losses not only for myself but for our whole team.


Christine is a nurse I always associate with some of the most traumatic cases on our unit. She seemed to be frequently at bedside with patients who quickly and dramatically decompensated-not because she was an incompetent nurse who contributed to their decompensation, but sometimes because of the sheer (bad) luck of the draw, and other times because she was such a strong nurse that she often got the sickest kids.


I remember coming onto shift one morning, and hearing about a little boy on our unit who'd been in town for a family vacation, contracted a yet-unknown infection, and suddenly coded and died just before we day shifters had arrived for work. When I heard it'd been Christine as the bedside nurse, my heart sank; she'd cared for three equally traumatizing cases in just the past two weeks. I found her, hugged her, and remember her saying, with uncharacteristic despair, "I hate it here. I hate it." I responded, "Of course you do. It's been awful for you here these days." She found her way through that dark season, and that hug was four years ago.


I have marveled over the past four years that she still found it in herself to keep coming back to our unit with ongoing tenderness and compassion toward every next patient she had. But she has come to the end of her road in our PICU and is giving herself permission to work in a different, less intense space. I'm truly relieved and glad for her. But I am again heartbroken. With her, I again feel the loss on the numbers level. I also feel the loss of the compassion that comes from a deep place in her, which she has modeled for all of us over the years. I feel the loss of her tight hugs after deeply painful shifts, those powerful acknowledgments that "I see you and I know what you've borne for your patient these past 12 hours, and I'm here to help hold some of that burden too."


I also can't help but wonder, when will I find myself at the end of my road with this patient population? I never imagined Christine would leave the PICU, and her departure soberly reminds me that we all have limits.


How to stop the bleed? With ongoing departures, we feel the ongoing staffing pinch, and the shift in overall skill level, as our unit's current nursing staff is younger in age, experience, and seniority. Please don't misunderstand; I am grateful for every new grad nurse, every traveler, every new hire who has joined us from other facilities. I'm grateful for them on a numbers level, and I am also looking forward to getting to know them and helping them acclimate to our unit.


But adjustment to and growing in trust with new staff take time. In a moment in history when our profession has endured so much heartache, stress, and uncertainty, I've found comfort in the familiar colleagues I've been to hell and back with over the years. We rose and fell through so many wild stories together, understood grief and hope and agony and beauty on levels like no other, and bonded deeply through the shared experiences and the rhythms we developed together at work to navigate them all.


I find myself wishing so much for easy, or at least easier, answers to stop the bleed from our staff. So much has dramatically changed because of the pandemic over the last two years, which continues to catapult more individuals and organizations into further change. An irony in the current situation is that positive changes for individuals are causing an equal and opposite reaction of negative changes for health care organizations.


What does this tell us about what needs to happen within these organizations? I don't know an easy answer. What I do know is that as someone who, for now, continues to stay within the same organization I've been with for 11.5 years, I am aching over the changes I'm navigating because of the loss of my most familiar and trusted colleagues.